Diagnosing Racism in Public Health: The Turnkey to Effective Interventions

Just as nutrition during the first 1000 days of a child’s life is important for development and lifetime health, a child’s place of birth and family socioeconomic characteristics are determinants of lifetime well-being and life expectancy. These are structural factors, often shaped generations in advance of any specific birth, that can lead to misdiagnosing the causes and effects of health and well-being.

Consider the following summary of factors affecting life expectancy in 65 662 census tracts across the United States in 2018:

Certain demographic qualities—high rates of unemployment, low household income, a concentration of Black or Native American residents and low rates of high school education—affected life expectancy in most neighborhoods. (https://bit.ly/3cHPc97)

This assessment conflates socioeconomic attributes with demographic identity, as if being Black or Native American itself limited life expectancy. The reason this seems to be true in the United Sates is the historical and specific exclusion of Black, Native American, and other non-White populations from the benefits of public investment in education, health care, neighborhood infrastructure, nutritional security, and other social and structural determinants of health.

The historical antecedents are the contest for, and appropriation of, the wealth-building “factors of production” of orthodox economic theory: land and labor. The contest for land took the form of explicit government campaigns of displacement and genocide of an estimated 5 to 10 million Native Americans in the present continental United States. This was implemented over a period of two centuries and was accompanied by the subsequent redistribution of those assets through laws such as the various Homestead Acts. Concomitantly, the contest for the labor of enslaved Africans and their descendants was waged over a period of 243 years. During this time, their labor was legally appropriated—labor with an estimated value of $5.9 to $14.2 trillion in 2009 dollars (https://bit.ly/3Qd9kxq). Note that this means that other people benefited and built wealth from the land and labor of Native Americans and enslaved Africans and their descendants.

The discriminatory cultural values of that era, which enabled and rationalized this systematic appropriation of wealth, were crisply articulated by Senator Stephen Douglas during his debates with Abraham Lincoln for the senatorial contest of 1858:

In my opinion this government of ours is founded on the White basis. It was made by the White man, for the benefit of the White man, to be administered by White men, in such manner as they should determine. . . . I am opposed to taking any step that recognizes the negro man or the Indian as the equal of the White man. (https://bit.ly/3cFWGtd)

This behavior was exacerbated after the Indian Wars and the passage of the Thirteenth Amendment (ending slavery) by converting surviving Native Americans into “wards of the state” and removing them to reservations and by methodically excluding African Americans from housing, education, and access to credit. These populations’ capacity to flourish in the aggregate was thereby limited. During the 20th century, policies that were intended to reduce poverty and elevate the standard of living of the population continued to actively discriminate against Native Americans, African Americans, and the successive waves of immigrant laborers who took the place of the formerly enslaved in the agricultural, construction, and hospitality industries.

The result was that the gap in wealth, well-being, and the social determinants of health widened between White and non-White groups during the 20th century.¹ The stark contrast in present wealth, homeownership, educational attainment, access to nourishing foods, and life expectancy between these demographic groups is therefore the expected result of these explicit intentions, policies, and actions.^2–4 In developed cash economies—where the majority of people do not produce their own food—food access, food security, and nutritional quality are direct correlates of economic standing. Consequently, factors that constrain and limit economic standing result in nutritional insecurity, with cascades of consequences for socioeconomic attainment.^5,6

Well-intentioned programs to ensure proper nutrition, development, and health during the first 1000 days of our lifetimes must acknowledge that not all children and families have equal starting points and that the reason for this is a history of explicitly racist policies and culture in the United States. The “racial reckoning” that the nation has experienced since summer 2020 indicates that our contemporary culture still grapples with the fundamental inconsistency between the racist foundations and norms of the nation and the largely unsupported propaganda about “equal opportunity” and “equality under the law.” A society that consistently reproduces income disparities across generations and that just happens to concentrate poverty and the attendant food and nutrition insecurity among populations of color—at over twice the poverty rate for Blacks and Hispanics as that of non-Hispanic Whites^7,8—is certainly not providing equal opportunity for all. Clearly, such outcomes are socially engineered.⁹

Failure to recognize this leads to futile interventions conflating the state of being inherently poor, uneducated, food insecure, and unhealthy with being made poor, uneducated, food insecure, and unhealthy. By contrast, proceeding from the recognition of historical and extant structural racism, researchers and health professionals can move from espousing “equality” to actively working toward, and producing, equity and justice. This means redressing the discriminatory history and behaviors that have produced today’s health disparities. Health interventions, policies, and programs will be more effective when social diagnoses and prescriptions are more accurate by virtue of being more truthful.